Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LN0000X | Nurse Practitioner - Neonatal | 4704142699 | MI |
NPI | 1053492462 |
---|---|
Provider Name | Mrs. Marivic Balasote |
First Address | Rochester Hills, MI 48309-3759 |
Second Address | Detroit, MI 48202-2608 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/10/2006 |
Last Update Date | 08/07/2007 |